Name:
Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma
Description:
Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma
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Duration:
T00H07M43S
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Upload Date:
2021-10-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER 1: Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma. This patient was 57-year-old female. Her chief complaint was headache and dizziness for three months. MMSE was 18 scores. And the laboratory findings are unremarkable. MRI showed the lesion located at the pineal region and back of third ventricle, which leads to obstructive hydrocephalus. A diagnosis was pineal region lesion, cavernous hemangioma most likely, accompanied by obstructive hydrocephalus.
SPEAKER 1: For the lesion located at the anterior side of pineal region, there are four approaches to access the lesion backward. Whether it is possible to access the lesion from anterior direction by endoscope, the answer is yes. The most commonly used approach is infratentorial supracerebellar approach. However, it might result in visual motor, acoustic motor, and hearing disturbances due to disrupting the pineal, superior and inferior colliculus in this case.
SPEAKER 1: In order to avoid these effects, tonsillouveal transaqueductal approach may be used. However, it may lead to postoperative obstructive hydrocephalus. So we decided to use anterior endoscopic transcortical approach to achieve endoscopic third ventriculostomy and resection of the aqueductal lesion. With a supine position, we used the left frontal linear incision.
SPEAKER 2: In the center of the brow is 2 centimeters ahead of Kocher’s point, which is the 3 centimeters anterior to the coronal sagittal and 2 centimeters away from midline. This approach enables us to achieve an ETV and also access the posterior third ventricle at the same time.
SPEAKER 1: This is the procedure of craniotomy. After entering the lateral ventricle, we use coagulator and scissors to enlarge interventricular foramen. We find the floor of third ventricle sinks and is adherent closely to the basilar artery. Then we coagulate and bluntly separated it.
SPEAKER 1: Subsequently, we use coagulator and scissors to make ETV and fully enlarge the fistula. Special attention should be paid to protect the basilar artery and surrounding vessels.
SPEAKER 1: Then I feel that fistula with the Gelfoam. After that, we seek the lesion backward. The lesion locates at the backside of the third ventricle. It is grapelike looking, and it obstructs the midbrain aqueduct. Firstly, we coagulate along the surface of the lesion in a circle.
SPEAKER 1: We recognize the boundary between the lesion and normal structures carefully. Then we coagulate to shrink the lesion and expand the operating space.
SPEAKER 1: We separate along the boundary of the lesion very carefully to protect brain tissue. The direction of separation should always be toward the lesion.
SPEAKER 1: The inlet of aqueduct is revealed after displacement of the lesion. Gelfoam is used to protect surrounding brain tissue. The lesion is hard and calcified. We cut and remove the lesion piece by piece.
SPEAKER 1: After the operation, the surgical field is clean and without hemorrhage. Finally, we've removed all the Gelfoam in the ventricle before the end of the surgery, and we check the fistula, which is fluent. At last, we made closure layer by layer, including surgery in the periosteum. Postoperative CT showed hydrocephalus alleviated. Postoperative MRI revealed gross resection of the lesion and also demonstrated our operative pathway.
SPEAKER 1: Fluent flowing of cerebrospinal fluid was confirmed in the CSF film three months postoperatively. Pathological findings show vascular tissue of different sizes and calcification, which confirms the diagnosis of cavernous hemangioma. The patient has slightly worsened irritation and concentration two days after operation, and no other early complication occurred.
SPEAKER 1: And MMSE score improved at three months postoperatively. Neurological specialist physical examination showed good recovery of the patient. Finally, here's the summary of the operation. First, surgical approach of neuroendoscopy, making needs tailoring to the individual lesion characteristics. Second, the correct procedure of that operation is first making a third ventriculostomy and then removing the lesion.
SPEAKER 1: Finally, the key point of the surgery is precise and careful anatomical separation and strict protection of surrounding tissues.